Multilayer reconstructions for defects overlying the Achilles tendon with the lateral-arm flap: long-term follow-up of 16 cases.

UNLABELLED: Defects of the Achilles tendon and the overlying soft tissue are challenging to reconstruct. The lateral-arm flap has our preference in this region as it provides thin pliable skin, in addition, the fascia and tendon can be included in the flap as well. The aim of this report is to share the experience the authors gained with this type of reconstruction. The authors report the largest series in the published reports today. PATIENTS AND METHODS: A retrospective review was performed of all patients treated between January 2000 and January 2009 with a lateral-arm flap for a soft-tissue defect overlying the Achilles tendon. RESULTS: In the reviewed period, 16 soft-tissue defects overlying the Achilles tendon were reconstructed, with a mean follow-up of 63 months. In three cases, tendon was included into the flap and in two, a sensory nerve was coapted. Fifteen cases (94%) were successful, one failed. In seven cases, a secondary procedure was necessary for thinning of the flap. CONCLUSION: The lateral-arm flap is a good and safe option for the reconstruction of defects overlying the Achilles tendon.

An unusual location of ulnar nerve pathology: a perineurioma of the ulnar nerve in the upper arm.

A young man presented with progressive motor weakness and atrophy of the ulnar muscles of his left hand over a period of more than 2 years. Electrodiagnostic studies indicated an ulnar nerve lesion, but it was not localized. High-resolution sonography of the ulnar nerve revealed an enlarged and hypoechogenic ulnar nerve at an unusual location, namely 12.5 cm proximal to the medial epicondyle. Histology showed that this was an intraneural perineurioma. High-resolution sonography of the ulnar nerve is very useful in the discovery of this unusual location of nerve pathology and may assist in its early detection.

Aesthetic refinements and reoperative procedures following 370 consecutive DIEP and SIEA flap breast reconstructions: important considerations for patient consent.

BACKGROUND: Breast reconstruction often requires multiple operations. In addition to potential complications requiring reoperation, additional procedures are frequently essential in order to complete the reconstructive process, with aesthetic outcome and breast symmetry shown to be the most important factors in patient satisfaction. Despite the importance of these reoperations in decision-making and the consent process, a thorough review of the need for such operations has not been definitively explored. METHODS: A review of 370 consecutive autologous breast reconstructions (326 patients) was undertaken, comprising 365 deep inferior epigastric artery perforator (DIEP) flaps and 5 superficial inferior epigastric artery (SIEA) flaps. The need for additional procedures for either complications or aesthetic refinement following initial breast reconstruction was assessed. RESULTS: Overall, there was an average of 1.06 additional interventions for every patient carried out after primary reconstructive surgery. Of 326 patients, 46 underwent early postoperative operations for surgical complications (0.17 additional operations per patient as a consequence of complications). Procedures for aesthetic refinement included those performed on the reconstructed breast, contralateral breast, or abdominal donor site. Procedures for aesthetic refinement included nipple reconstruction, nipple-areola complex tattooing, dog-ear correction, liposuction, lipofilling, scar revision, mastopexy, and reduction mammaplasty. CONCLUSION: While DIEP flap surgery for breast reconstruction provides favorable results, patients frequently require additional procedures to improve aesthetic outcomes. The need for reoperation is an important part of the consent process prior to reconstructive surgery, and patients should recognize the likelihood of at least one additional procedure following initial reconstruction.

Anteromedial thigh flaps: an anatomical study to localize and classify anteromedial thigh perforators.

Until now, research on flaps in the anteromedial thigh region has focused on flaps in specific regions. To elucidate the complete pattern of suitable anteromedial thigh perforators, an anatomical study was performed by dissecting nine thighs from different cadavers. The ideal perforator has maximum length and diameter and runs through a septum. According to the data found in our study, these perforators can predominantly be found in the middle third of the anteromedial thigh region. All of the three main thigh vessels supply perforators which can be used for flaps. Pertaining to length and diameter the most suitable perforators originate from the deep femoral artery, which can be found in the proximal and middle third of the anteromedial thigh. Musculocutaneous perforators are found to be longer than septocutaneous perforators. Because of their position, the proximal and distal third perforators should preferentially be used for local pedicled flaps. Defects in the pelvic area and around the knee can be closed with perforator flaps from the proximal and distal anteromedial thigh, respectively. Because of their diameter, length, and number, the middle third perforators should be the first choice for harvesting free flaps. Skin closure is easily achieved in the anteromedial thigh region even when larger flaps are used.

Hypopharyngeal reconstruction with an anterolateral thigh flap after laryngopharyngeal resection: results of a retrospective study on 20 patients.

The aim of this retrospective study is to evaluate short- and long-term postoperative morbidity and mortality of hypopharyngeal resection and reconstruction. Patients with laryngopharyngeal malignancies were treated with laryngopharyngectomy and the resulting defect was reconstructed with an anterolateral thigh flap. The study group consisted of 20 patients with one or more primary hypopharyngeal carcinomas or a relapse of this tumour. All patients were diagnosed and operated in the University Medical Center between February 2000 and July 2007. Data were collected from the clinical medical files of the departments of plastic surgery and oto-rhino-laryngology. The dietetic and speech therapy files were used as well. To study the quality of life, the Dutch version of the University of Washington Quality of Life questionnaire was sent to all surviving patients. The microsurgical reconstructions were 100% successful. Fifteen patients (75.0%) died during the follow-up period; the 5-year overall survival was 20%. Complications such as post-surgical fistulas and strictures requiring surgical intervention were found in five (25.0%) and six patients (30.0%), respectively. Other post-surgical complications such as wound dehiscence were seen in two patients (10.0%). The incidence of donor-site complications at the thigh was very low. No significant relationship was found among preoperative patients' characteristics like age, gender, preoperative radiotherapy, the TNM (tumour, node, metastasis) classification of the tumour and the risk of post-surgical complications. The number and/or the severity of the complications were not significantly associated with the duration of surgery or ischaemia time. In our view, surgery is a good option in the treatment of these patients. Although curative treatment is the best outcome, a satisfactory palliation in itself can be a justification for this type of surgery. Although only seven patients were able to answer the QOL questionnaire, the positive judgements of these patients support this view point.

The nasolabial fold as potential vascular receptor site: an anatomic study.

Free and pedicled flaps are frequently used in reconstruction of the lower two-thirds of the face. For these reconstructions, the submandibular facial vessels are extensively used as a receptor site. In this anatomic study, we investigate if the facial vessels in the nasolabial fold can be used as a receptor site as well. In 13 human cadavers, the facial artery and vein were dissected in the nasolabial fold in the same way as would be done during surgery. The ease of dissection and length, diameter, and location of the vessels were analyzed. The average length of the dissected artery was 28 mm (+/-11 standard deviations [SD]) and of the dissected vein, 19 mm (+/-6 SD). The mean diameter of the artery was 1.5 mm (+/-0.4 SD) and 2.5 mm (+/-0.8 SD) for the vein. In 85% of the sides, both vessels were suitable to use as a microsurgical receptor site. The easy access and the measured diameter of the facial vessels in the nasolabial fold make it a potential site for microsurgical anastomosis.

Clinical experience with the nasolabial fold as receptor site in microvascular reconstruction.

We report our experience using the vessels at the nasolabial fold as receptor site in free tissue transfer in head and neck reconstructions; a site that proved more convenient than the submandibulary site in selected cases. Six cases as well as the dissection technique of the nasolabial fold are reported. No complications occurred during or post surgery and in all cases the vessels were of adequate diameter for an end to end anastomosis. The advantages this site offers are discussed.

Early reintervention of compromised free flaps improves success rate.

INTRODUCTION AND AIM: To develop a protocolized monitor schedule in microvascular free flap reconstruction, we investigated a possible correlation between the outcome and the interval between clamp release and start of revision. MATERIALS AND METHODS: All the charts of patients treated between 2000 and 2006 with a free flap were evaluated. The patients who underwent a flap revision were further analyzed. RESULTS: A total of 608 free flaps were evaluated; 69 of these flaps were revised. Most vascular complications took place within the first 24 h; the latest complication was observed 8 days after surgery. After 6 days post surgery, the number of revisions decreased considerably. With regard to the salvaged flaps the mean time to start the revision was 46.5 h (SD 39). With regard to the failed revisions, the mean time to start the revision was 82.0 h (SD 47). This difference proved significant (P = 0.006). CONCLUSION: Our data shows that the majority of anastomotic failures occur within the first 24 h. Thereafter, the frequency of failures decreases. We also found that the time between initial reconstruction and start of the salvage procedure influences the outcome of the revision negatively.

Octyl-2-cyanoacrylate tissue glue (Dermabond) versus Monocryl 6 x 0 Sutures in lip closure.

OBJECTIVE: To assess the value of octyl-2-cyanoacrylate tissue glue in lip closure versus Monocryl stitches. DESIGN: Closure of a cleft lip can be done using transcutaneous Monocryl 6 x 0 sutures or using octyl-2-cyanoacrylate tissue glue (Dermabond). In 15 consecutive patients, the cleft lip was closed with Monocryl 6 x 0 and in another 15 consecutive patients, Dermabond was applied. Outcome parameters were complications, satisfaction of the parents with the cosmetic result, and the cosmetic result as judged by professionals. Satisfaction of the parents was assessed using a questionnaire and a visual analog scale. The cosmetic result as judged by professionals was measured by rating standardized pictures according to a visual analog scale. SETTING: A tertiary referral center for children with craniofacial anomalies. RESULTS: Complications were equal in both patient groups (p = .273). Satisfaction of the parents, as well as the professionals, with the cosmetic result did not show significant differences between the Monocryl 6 x 0 and the Dermabond groups (p = .922 and .983, respectively). However, parents were significantly more positive about the cosmetic result than the professionals were (p = .000). CONCLUSION: The results of lip closure using Dermabond tissue glue equal the cosmetic results of lip closure using transcutaneous Monocryl 6 x 0 sutures.

The use of the pedicled supraclavicular flap in noma reconstructive surgery.

Three noma patients with large unilateral facial defects were reconstructed using the pedicled supraclavicular flap technique in the Noma Children Hospital in Sokoto, Nigeria. The results are-although not completely perfect-encouraging enough to report and to repeat the technique in future reconstructive noma surgery after moderate modifications. It is advised not to tunnel the pedicle in the neck, but instead to open the neck. Then, the flap can be inset in a Z-plasty fashion to close the neck without the chance of compression of the pedicle of the flap. In this way flap necrosis can be prevented, without the risk of a scar contracture of the neck. Another technique, which can prevent partial flap necrosis and loss of tissue, with the need for secondary stage interventions, is a delay procedure of the flap. Incorporation of the fascia in the pedicled supraclavicular flap can be another option to fulfil the abovementioned requirements.

DBM induced ectopic bone formation in the rat: the importance of surface area.

Demineralized bone matrix (DBM) has been shown to induce ectopic endochondral bone formation, when intramuscularly implanted in rats. In earlier studies we have found a variation in bone formation capacity of this DBM. This might be due to the properties of the DBM itself, but the use of DBM blocks could be of influence as well. Therefore, this study was designed to investigate whether increasing the surface area of the DBM by morsellizing, influences the bone formation capacity. In view of this, DBM implants and morsellized DBM (MDBM) implants were placed intramuscularly in a rat model. At six weeks the implants were retrieved and evaluated by histology and histomorphometry. The results demonstrated that significant amounts of newly formed bone were present in some DBM as well as some MDBM implants while in others no, or very little new bone was found. Histomorphometric analysis showed an average bone formation of 2.6% in DBM implants and an average of 1.9% in MDBM implants. Still, the amount of bone formation was limited compared with previous studies. It is concluded that enlargement of the surface area by morsellizing DBM implants is not an important factor in bone forming capacity.

Ectopic bone formation in rats: the importance of the carrier.

Much research has been done to develop the ideal bone graft substitute (BGS). One approach to develop this ideal BGS is the use of growth factors, but for this approach osteoprogenitor cells are needed at the site of reconstruction. An alternative is a cell-based approach, where enough cells are provided to form bone in a carrier material. In previous studies of our group, titanium (Ti) carriers have been used, because of the excellent mechanical properties and the bone-compatibility of this material. On the other hand, calcium phosphate (CaP) ceramics are known for their excellent osteoconductivity. The aim of this study is to investigate the influence of the carrier in a cell-based bone regeneration approach, whereby we hypothesize that CaP-ceramic implants will induce more bone formation than Ti-fiber implants, in the same animal model as our previous experiment. Ti-fiber mesh implants and ceramic implants were seeded with rat bone marrow cells (RBM) and implanted subcutaneously. Histological analysis after one, three and six weeks showed differences in the way of bone formation in the two groups: bone appeared to grow from the center to the periphery of the implant in the titanium group, while bone formation in the ceramic group occurred through the whole implant. Histomorphometrical analysis after one week showed very limited bone formation for both the titanium and ceramic group. At three weeks, the amount of bone formation was increased till about 10% for the titanium group and 18% for the ceramic group. No significant difference between the two groups could be observed. In the six week group, the bone formation was 6% (Ti) and 23% (CaP), respectively (P < 0.001). Further, bone formation started earlier in the CaP-ceramic scaffolds than in the Ti scaffolds. Our hypothesis could be confirmed: ceramic implants induce more bone formation than titanium implants.

Demineralized bone matrix-induced ectopic bone formation in rats: in vivo study with follow-up by magnetic resonance imaging, magnetic resonance angiography, and dual-energy X-ray absorptiometry.

The aim of this study was to further explore the use of magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and dual-energy X-ray absorptiometry (DEXA) to assess bone formation and blood circulation in a pedicled bone graft substitute. In 14 Wistar rats, initially 10 weeks old, heterogeneous demineralized femur bone matrix implants were wrapped in pedicled adductor thigh muscle flaps. One rat died after surgery. Subsequently, bone formation and maintenance of blood vessel functionality were evaluated in six rats 6 weeks postimplantation by means of in vivo MRI/MRA and postmortem histomorphometry. The other seven rats were left for 12 weeks, whereafter bone formation was evaluated by in vivo DEXA and postmortem histomorphometry. The results demonstrated that after 6 weeks bone formation was present in four of six animals, quantified as 42 (+/-35)% and 25 (+/-19)% by means of MRI and histomorphometry, respectively. MRA was able to show patency of the pedicles of these four rats only, which suggests that the lack of blood supply in the other two rats is the cause of the failure to form bone. In the 12-week group, histology showed increased bone formation without signs of osteolysis, which was quantified histomorphometrically to be as high as 48 (+/-15)%. DEXA failed to show bone formation. It is concluded that in vivo MRI proved to be a reliable method for monitoring ectopic bone formation in a rat model, whereas in vivo DEXA was unable to detect the implants. Furthermore, in vivo MRA proved to be a useful technique for studying the circulation of muscle flaps in this animal model.

Ectopic bone formation in rats: the importance of vascularity of the acceptor site.

Bone graft substitutes (BGS) can be fabricated by the combination of three key ingredients: (1) competent bone-forming cells, (2) a suitable framework or scaffold, and (3) the presence of biological stimulants. Although much research has been done to develop the ideal BGS, still the results are not very consistent. In view of this, the cellularity and vascularity of the recipient site are supposed to be important for the osteoinductive capacity of BGS. Therefore, we hypothesized that a muscle recipient site could favor bone formation in a cell-based BGS compared to a subcutaneous recipient site due to the higher vascularity of muscle tissue. To prove this hypothesis, 48 titanium fiber mesh implants were seeded with rat bone marrow stromal cells (RBM) and implanted subcutaneously and intramuscularly in the adductor thigh muscle of rats. The amount of bone formation after 1, 3 and 6 weeks was evaluated by histology and histomorphometry as well as by calcium content. Analysis revealed that the bone formation increased during implantation. However, bone formation did not exceed 12% of the implant surface, both for the intramuscular and subcutaneous recipient site. Also, no significant differences in bone amount between these two sites existed. Consequently, our hypothesis could not be confirmed.

Donor-site morbidity after free vascularized autogenous fibular transfer: subjective and quantitative analyses.

The purpose of this study was to determine the subjective and quantitative donor-site morbidity after removal of a free vascularized fibula flap for autoreconstruction. Ten patients and six age-matched, healthy control subjects were included in this study. The postoperative periods ranged from 6 to 87 months. Subjective donor-site morbidity was assessed with a patient questionnaire and the Enneking system. For quantification of donor-site morbidity, gait was evaluated during normal walking, walking under visual and cognitive constraints, and walking at a velocity higher than the preferred one. In general, the patient perception of donor-site morbidity was low. Complaints were frequently mentioned, however, including pain (60 percent), dysesthesia (50 percent), a feeling of ankle instability (30 percent), and inability to run (20 percent). Gait analyses revealed that patients walked at a lower preferred velocity, compared with control subjects. Furthermore, they demonstrated significant increases in the coefficients of variation of stride time during walking under visual and cognitive loads and during walking at a velocity higher than the preferred one, compared with normal walking. These increases were not observed for control subjects. These findings suggest that the reautomatization of gait is affected among patients. This study demonstrates that fibula harvesting is associated with low subjective morbidity but frequent complaints. Walking during complex tasks and at high velocities reveals that restoration of gait is not complete after partial fibulectomy.

Contralateral reinnervation of midline muscles in nonidiopathic facial palsy.

The purpose of this study was to analyze contralateral reinnervation of the facial nerve in eight patients with complete facial palsy after surgery or trauma and seven healthy volunteers. All patients had contralateral reinnervation of facial muscles as demonstrated by electrical nerve stimulation versus none of the control subjects. Four patients had facial muscle movements at the site of the damaged nerve. In one patient this was entirely the result of contralateral reinnervation, whereas the other three patients had innervation both ipsilaterally and contralaterally. This implies that renewed facial muscle activity should be examined considering the origin of the reinnervation, either contralateral or ipsilateral. Contralateral reinnervation is a common phenomenon after total facial palsy and can occur alongside ipsilateral reinnervation. It can be mistaken for adequate reinnervation of the damaged nerve, causing postponement of dynamic reconstruction therapy.